Exam Review
- Which interventions should a nurse prioritize for a client with suspected spinal cord injury during initial assessment in ABCDE trauma care? (Select all that apply)(SATA)A)Administer IV fluids to manage blood pressureB)Maintain cervical spine precautionsC)Initiate cardiopulmonary resuscitationD)Perform a focused neurological assessmentE)Assess airway and breathing activelyF)Apply a tourniquet to bleeding limbs
- A nurse is assessing a client on a medical-surgical ward complaining of excessive sweating and difficulty sleeping. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.✓Provide beta- blockers✓Reduce environmental stimuli✓Thyroid storm✓Blood glucose levels✓Serum calciumActions to Take Choices✕Monitor for seizures✓Provide beta- blockers✕Administer antipyretics✓Reduce environmental stimuliPotential Conditions Choices✕Hyperparathyroidism✕Diabetes Insipidus✕Hypothyroidism✓Thyroid stormParameters to Monitor Choices✓Blood glucose levels✕Oxygen saturation✓Serum calcium✕Liver function
- A nurse is assessing a client who was admitted to the hospital after a vehicle accident. Exhibits Drag the words from the choices below to fill in each blank in the following Sentence Important steps in managing clients with suspected head injury during initial assessment include ▾ evaluating and supporting airway and ventilation , ▾ performing a Glasgow Coma Scale evaluation and ▾ maintaining cervical spine precautionsDropdown 1:Option 1: performing a Glasgow Coma Scale evaluationOption 2: assessing for delayed signs of spinal stenosisOption 3: evaluating and supporting airway and ventilationOption 4: observing for signs of basilar skull fractureOption 5: maintaining cervical spine precautionsOption 6: collecting subjective data about the mechanism of injuryDropdown 2:Option 1: performing a Glasgow Coma Scale evaluationOption 2: assessing for delayed signs of spinal stenosisOption 3: evaluating and supporting airway and ventilationOption 4: observing for signs of basilar skull fractureOption 5: maintaining cervical spine precautionsOption 6: collecting subjective data about the mechanism of injuryDropdown 3:Option 1: performing a Glasgow Coma Scale evaluationOption 2: assessing for delayed signs of spinal stenosisOption 3: evaluating and supporting airway and ventilationOption 4: observing for signs of basilar skull fractureOption 5: maintaining cervical spine precautionsOption 6: collecting subjective data about the mechanism of injury
- What is an essential nursing action in the evaluation of fluid therapy in a patient with HHS?A)Checking blood pressure every hourB)Measuring the patient's urine outputC)Assessing capillary refill timeD)Monitoring patient anxiety levels
Exam Review
- A patient with diabetes is learning about insulin administration. Which statement by the patient indicates the need for further teaching?A)I will rotate injection sites to avoid lipodystrophy.B)I should administer insulin before meals to manage blood sugar levels effectively.C)It's okay to inject insulin through clothes if I'm in a hurry.D)I will watch for signs of hypoglycemia after insulin administration.
- A patient with diabetes mellitus is starting a new medication that increases insulin sensitivity. What key teaching point should the nurse include?A)Monitor for signs of hypoglycemia regularly.B)The medication should be taken only during hypoglycemic episodes.C)The medication will replace any need for dietary changes.D)Regular blood glucose monitoring is unnecessary.
- A nurse is evaluating a client in a primary care clinic who reports intermittent sensation of fatigue and weight changes. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.✓Monitor daily caloric intake✓Provide education on symptom tracking✓Hypothyroidism✓Body weight✓Thyroid hormone levelsActions to Take Choices✕Administer glucose intravenously✓Monitor daily caloric intake✓Provide education on symptom tracking✕Conduct a neurological assessment✕Prescribe insulin injectionPotential Conditions Choices✕Pheochromocytoma✕Hyperthyroidism✕SIADH✓HypothyroidismParameters to Monitor Choices✓Body weight✓Thyroid hormone levels✕Cholesterol✕Blood glucose levels✕Calcium levels
- A nurse is assessing a client admitted to the hospital after sudden neurological deficits. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress✓Elevate the head of the bed✓Initiate administration of thrombolytic therapy✓Cerebral vascular accident✓Blood pressure trends✓Neurological status assessments using GCSActions to Take Choices✕Provide a warm compress for client comfort✕Administer oxygen therapy✓Elevate the head of the bed✕Start an intravenous fluid bolus✓Initiate administration of thrombolytic therapyPotential Conditions Choices✕Brain ischemia due to hypoxia✓Cerebral vascular accident✕Acute spinal cord injury✕Intracranial hemorrhageParameters to Monitor Choices✓Blood pressure trends✕Oxygen saturation levels✕Pain level✕Presence of periorbital ecchymosis✓Neurological status assessments using GCS
Exam Review
- When conducting an initial assessment for a client with suspected head injury, what is the first step according to the ABCDE trauma assessment?A)Check for bruising and swelling on the head.B)Expose the client to evaluate for other injuries.C)Assess disability using the Glasgow Coma Scale.D)Secure the airway while maintaining cervical spine precautions.
- A nurse is coordinating care for a client in a rehabilitation center. In managing a client with severe electrolyte imbalances due to endocrine dysfunction, which actions should a nurse anticipate or contraindicate?
Anticipated Contraindicated Administer diuretics to support electrolyte balance ✓ Monitor neurological status regularly ✓ Initiate fluid therapy to manage dehydration ✓ Restrict oral intake to prevent fluid overload ✓ - A nurse is evaluating a patient who presents to the emergency department for episodes of confusion and lethargy. Which of the following neurological complications are associated with endocrine emergencies? Select all that applyA)Diabetic ketoacidosis (DKA)B)PheochromocytomaC)Cerebral vascular accidentD)HyperparathyroidismE)Increased cranial pressureF)Spinal cord injury
- A nurse is educating a patient about the differences between ischemic and hemorrhagic strokes. Which statement by the patient indicates a correct understanding?A)Ischemic strokes are caused by obstructions blocking blood flow to the brain.B)Hemorrhagic strokes have the same treatment regimen as ischemic strokes.C)Hemorrhagic strokes result from the abrupt blockage of arteries to the brain.D)Ischemic strokes are caused by ruptured blood vessels leading to brain bleeding.
Exam Review
- An adult patient with hyperthyroidism presents with increased appetite, weight loss; and restlessness. Which lab value is most consistent with overt hyperthyroidism?A)Decreased TSH and increased T4B)Normal TSH and increased T4C)Increased TSH and decreased T4D)Decreased TSH and normal T4
- In assessing a person with a suspected spinal cord injury, which sign would most prompt the need for immediate stabilization?A)Mild pain near the injury location.B)Increased reflexes observed during physical examination.C)Development of muscle spasms at the injury site.D)Loss of sensation below the level of suspected injury.
- A nurse is evaluating a client undergoing treatment in an outpatient setting. Given the context of diabetes insipidus (DI) management, evaluate the client's latest laboratory findings to determine necessary nursing actions for managing electrolyte imbalances.A)Low urine specific gravityB)Normal glucose levelsC)Elevated serum sodium levelsD)Dry mucous membranes
- A patient is prescribed rapid-acting insulin lispro to manage postprandial blood glucose levels. Based on its pharmacokinetics, when should the nurse educate the patient to monitor for a peak effect of this medication?A)4 hours after injectionB)1 hour after injectionC)15 minutes after injectionD)Immediately after injection
Exam Review
- What is the first step a nurse should take in the treatment of a patient presenting with diabetic ketoacidosis (DKA)?A)Begin an insulin drip immediatelyB)Provide oral glucoseC)Administer potassium supplementsD)Initiate intravenous fluid replacement
- A nurse is assessing a client in the emergency department presenting with an altered mental state and generalized swelling. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- For a client post-cerebral vascular accident with a nasogastric tube, what should a nurse monitor closely to prevent complications?A)Frequency of client's bowel movements.B)Use of IV fluids alongside feedings.C)Client's ability to swallow liquids.D)Positioning of the tube before nasogastric feedings.
- What is the priority intervention for an adult patient diagnosed with hyperparathyroidism to prevent long-term complications?A)Administer daily calcium supplementsB)Encourage increased fluid intakeC)Initiate a high-calcium dietD)Provide vitamin D injections
Exam Review
- A nurse is preparing to administer regular insulin to a client before lunch. If the insulin is given at 11:00 AM, at what time should the nurse expect the medication to peak?A)3:00 PMB)11:30 AMC)1:00 PMD)12:00 PM
- During the initial ABCDE trauma assessment of a client with suspected head injury, which intervention is the priority to prevent further neurological damage?A)Performing a detailed inspection and palpation of the head for visible signs of trauma.B)Initiating intravenous fluid therapy immediately to maintain circulation.C)Collecting subjective data about the mechanism and time of injury.D)Maintaining cervical spine precautions while evaluating airway and ventilation.
- An adult patient with subclinical hyperthyroidism has routine lab results. What finding would most likely be observed in their lab values?A)Increased TSH levels with decreased T4 levelsB)Elevated TSH levelsC)Normal TSH levelsD)Decreased TSH levels with normal T4 levels
- A client visits the clinic for evaluation of persistent leg discomfort. Which 3 findings should the nurse prioritize for this client with suspected spinal stenosis?A)Occasional back stiffnessB)Elevated blood pressureC)Chronic leg painD)Reduced sensation in lower extremitiesE)Diminished reflexes in the ankle area